P - 79005REQUEST FOR ELECTRICAL WSPECTION
1� 6 3 9>� �`t 1 � Minnesota Board of Efectricity
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
E (651) 642-�8�0 T f Y IM R S 1- 8 � 0- 6 2 7- 3 5 2 9 www.e lec trici ty.s ta te.mn.us
lilll lil� lllll lilll llIII IIIII IIIII II111 �� I�
16397473
/ , ,,
i�
�oo�, o �oyy � ,�''
Req Date: Rough-in Inspection Required7 ❑ Yes ❑ No Inspection Other Than RougMn: ❑Ready Now I Call
��� You must call the inspecta when ready! Date Ready. a��
I certify tliat I am the LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
.ton srte nadress �s�ree�. �. «� ra.� cnv . ra coae
BACK 6F YELLOW COPY
�V��[� �
�
Power Suppli� Address
� Con Lic
�le � �
� ing InstaYation
I
�
or Qwner Performing Installatbn)
�
BOARD � ELECIRICRY CAPV
.�� �
Mast� Eledridan a Power Limited Technidan
License Numberl�����r�yjy�/Ll.�
��J�L
� ��
--r
�,S -�3��5�
EB-00001A-14 8.1.2002